| NPI | 1194961904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA06380) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11282) |
| 363A00000X Physician Assistant (Licence: GA 10383) | |
| 363A00000X Physician Assistant (Licence: CA PA59643) | |
| 363AM0700X Physician Assistant, Medical (Licence: UT 12215796-1206) | |
| 363A00000X Physician Assistant (Licence: MO 2021021702) | |
| 363A00000X Physician Assistant (Licence: NY 013074) | |
| 363AM0700X Physician Assistant, Medical (Licence: OK 3099) | |
| 363AM0700X Physician Assistant, Medical (Licence: MI 5601010504) | |
| Enumeration Date | 2008-12-29 |
| Last Update Date | 2021-08-10 |