| NPI | 1104844224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 8469216-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NV PA654) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2013-08-19 |