| NPI | 1992463970 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PA1128) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-2185) |
| Enumeration Date | 2021-12-07 |
| Last Update Date | 2024-12-11 |