| NPI | 1235535931 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 11224536-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 2364) |
| Enumeration Date | 2014-11-07 |
| Last Update Date | 2024-10-25 |