| NPI | 1023541208 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10827269) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 54271) |
| Enumeration Date | 2017-04-05 |
| Last Update Date | 2024-05-20 |