| NPI | 1275706830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA06202) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA19649) |
| 363A00000X Physician Assistant (Licence: PA MA053771) | |
| 363A00000X Physician Assistant (Licence: AZ 4362) | |
| Enumeration Date | 2008-04-03 |
| Last Update Date | 2012-07-19 |