| NPI | 1093707143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 52699) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA04339) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2005-08-16 |
| Last Update Date | 2022-03-27 |