| NPI | 1003898198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 285002-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NV PA-C97) |
| Enumeration Date | 2005-11-15 |
| Last Update Date | 2022-02-24 |