| NPI | 1245239201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: CA 16836) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TX PA03053) |
| Enumeration Date | 2005-07-20 |
| Last Update Date | 2007-07-08 |