| NPI | 1326198110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA11712) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 00703) |
| 363AM0700X Physician Assistant, Medical (Licence: MA 902) | |
| Enumeration Date | 2007-01-12 |
| Last Update Date | 2023-11-01 |