| NPI | 1164856886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-41920) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 8776901-1206) |
| Enumeration Date | 2013-08-29 |
| Last Update Date | 2024-02-19 |