| NPI | 1265719868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12799) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 5487) |
| 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00263900) | |
| Enumeration Date | 2011-11-10 |
| Last Update Date | 2023-03-17 |