| NPI | 1023253754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8256806-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA-784) |
| Enumeration Date | 2008-12-09 |
| Last Update Date | 2017-05-12 |