| NPI | 1255350708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA03742) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05045) |
| 363AS0400X Physician Assistant, Surgical (Licence: ME PA001081) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA03742) | |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2021-09-17 |