| NPI | 1114974300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MD C02065) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C02065) |
| 363A00000X Physician Assistant (Licence: TX PA06000) | |
| Enumeration Date | 2006-05-31 |
| Last Update Date | 2019-07-30 |