| NPI | 1043975923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 14198797-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA9356) |
| Enumeration Date | 2021-11-04 |
| Last Update Date | 2025-02-26 |