| NPI | 1154625739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 7877599-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2010-12-22 |
| Last Update Date | 2025-01-23 |