| NPI | 1174548069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX 11010) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110840704) |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2023-06-20 |