| NPI | 1124161278 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA08623) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VT 104-0000126) |
| 363AS0400X Physician Assistant, Surgical | |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2015-02-08 |