| NPI | 1205874179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 319284-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: ID PA509) |
| Enumeration Date | 2006-06-03 |
| Last Update Date | 2023-09-22 |