| NPI | 1275818155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10174240-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 4985) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 4985) | |
| Enumeration Date | 2011-10-11 |
| Last Update Date | 2023-11-27 |