| NPI | 1215446919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: UT 10498761-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: UT 10498761-1206) |
| Enumeration Date | 2017-09-25 |
| Last Update Date | 2017-09-25 |