| NPI | 1972130565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207XX0005X Orthopaedic Surgery, Sports Medicine (Licence: WY PA893) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY PT893) |
| Enumeration Date | 2020-03-24 |
| Last Update Date | 2024-12-13 |