| NPI | 1205195088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| 363AM0700X Physician Assistant, Medical (Licence: UT 10749979-1206) | |
| Enumeration Date | 2012-05-14 |
| Last Update Date | 2023-10-30 |