| NPI | 1164404034 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA04666) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CA Pa19287) |
| Enumeration Date | 2005-11-16 |
| Last Update Date | 2021-12-01 |