| NPI | 1083954275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 6359771-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 22844) |
| Enumeration Date | 2013-02-25 |
| Last Update Date | 2023-04-07 |