| NPI | 1306198924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 4850503-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: UT 4850503-1206) |
| 363AM0700X Physician Assistant, Medical (Licence: UT 4850503-1206) | |
| Enumeration Date | 2012-10-05 |
| Last Update Date | 2022-03-06 |