| NPI | 1275800336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 6395363-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11021) |
| Enumeration Date | 2011-11-17 |
| Last Update Date | 2021-05-12 |