| NPI | 1265903496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10995993-1206) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: OR PA191109) |
| Enumeration Date | 2018-12-16 |
| Last Update Date | 2022-12-03 |