| NPI | 1134198419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8441754-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AZ 3301) |
| 363AS0400X Physician Assistant Surgical (Licence: AZ 3301) | |
| Enumeration Date | 2006-03-17 |
| Last Update Date | 2023-11-01 |