| NPI | 1043665789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1448) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA08766) |
| Enumeration Date | 2016-05-02 |
| Last Update Date | 2018-06-29 |