| NPI | 1114259363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA07490) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA20826) |
| Enumeration Date | 2010-02-12 |
| Last Update Date | 2021-04-22 |