| NPI | 1174730816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA09849) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM 99-PA26) |
| Enumeration Date | 2007-05-16 |
| Last Update Date | 2022-07-21 |