| NPI | 1316938673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7060654-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OK 1391) |
| Enumeration Date | 2005-11-04 |
| Last Update Date | 2011-07-25 |