| NPI | 1255322749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 9287746-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NV NCCPA 1049736) |
| Enumeration Date | 2005-11-02 |
| Last Update Date | 2019-09-12 |