| NPI | 1205139763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 8704098-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 4724) |
| Enumeration Date | 2010-12-06 |
| Last Update Date | 2021-11-19 |