| NPI | 1245332618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA17103) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA PA56711) |
| 363AM0700X Physician Assistant, Medical (Licence: MI 5601003836) | |
| Enumeration Date | 2006-09-05 |
| Last Update Date | 2024-01-22 |