| NPI | 1164666061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7819497-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: UT 7819497-1206) |
| Enumeration Date | 2009-04-23 |
| Last Update Date | 2023-05-23 |