| NPI | 1104929892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA07427) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AK 920) |
| 363AS0400X Physician Assistant, Surgical (Licence: CA PA 14720) | |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 4871) | |
| Enumeration Date | 2006-09-07 |
| Last Update Date | 2011-12-28 |