| NPI | 1174594808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 2136) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA04283) |
| Enumeration Date | 2006-01-31 |
| Last Update Date | 2012-08-01 |