| NPI | 1073981437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12262766-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05928) |
| Enumeration Date | 2015-09-02 |
| Last Update Date | 2021-05-07 |