| NPI | 1124200548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2015037343) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA05282) |
| Enumeration Date | 2007-11-27 |
| Last Update Date | 2025-03-12 |