| NPI | 1033815980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 13234382-1206) |
| Enumeration Date | 2023-02-02 |
| Last Update Date | 2025-07-31 |