| NPI | 1225482201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 11433468-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 11433468-8906) |
| 363AM0700X Physician Assistant, Medical (Licence: ID PA-1455) | |
| Enumeration Date | 2016-04-15 |
| Last Update Date | 2026-07-15 |