| NPI | 1174967780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA08327) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA219358) |
| Enumeration Date | 2013-04-25 |
| Last Update Date | 2026-03-11 |