| NPI | 1134277445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TX PA14904) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY 1045432) |
| 363AM0700X Physician Assistant Medical (Licence: VA 1045432) | |
| Enumeration Date | 2007-01-05 |
| Last Update Date | 2021-12-11 |