| NPI | 1154179844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 14245351-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 14245351-1206) |
| Enumeration Date | 2024-05-08 |
| Last Update Date | 2025-11-21 |