| NPI | 1972805943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-1084) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA60193367) |
| 363AM0700X Physician Assistant, Medical (Licence: UT 10927277-1206) | |
| Enumeration Date | 2010-11-24 |
| Last Update Date | 2023-06-23 |