| NPI | 1144777418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8464916-8906) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 8464916-1206) |
| Enumeration Date | 2016-09-05 |
| Last Update Date | 2021-12-20 |