| NPI | 1235820614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 14033501-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ Pending) |
| Enumeration Date | 2023-05-17 |
| Last Update Date | 2024-07-03 |