| NPI | 1093391450 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12492705-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: UT 12492705-8906) | |
| 363A00000X Physician Assistant (Licence: CA PA59778) | |
| Enumeration Date | 2021-03-24 |
| Last Update Date | 2021-11-29 |