| NPI | 1134405061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 367H00000X Anesthesiologist Assistant (Licence: TX 789790374) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 4972) |
| Enumeration Date | 2011-10-24 |
| Last Update Date | 2025-02-19 |