| NPI | 1033202775 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 367H00000X Anesthesiologist Assistant (Licence: FL AA918) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: TX PA03532 (INACTIVE)) |
| 363AM0700X Physician Assistant Medical (Licence: FL PA9104159) | |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2024-02-09 |