| NPI | 1316091325 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09276) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA03097) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2019-08-16 |