| NPI | 1013074004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA18014) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA-9101291) |
| 363A00000X Physician Assistant (Licence: CA PA-54805) | |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA- 9101291) | |
| Enumeration Date | 2007-01-02 |
| Last Update Date | 2024-10-15 |