| NPI | 1184249138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12456910-1206) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 12456910-1206) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-06-15 |
| Last Update Date | 2024-03-04 |