| NPI | 1205480738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 11522934-1206) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 363A00000X Physician Assistant (Licence: UT 11522934-1206) | |
| Enumeration Date | 2019-08-01 |
| Last Update Date | 2023-03-29 |