| NPI | 1013538883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12757354-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA0485) |
| Enumeration Date | 2020-05-02 |
| Last Update Date | 2022-07-19 |