| NPI | 1124330865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10912261-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA1078) |
| 363A00000X Physician Assistant (Licence: CO PA3028) | |
| Enumeration Date | 2010-07-10 |
| Last Update Date | 2019-07-10 |