| NPI | 1336130889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 6124415-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA907) |
| 363A00000X Physician Assistant (Licence: CA PA17883) | |
| Enumeration Date | 2005-11-03 |
| Last Update Date | 2021-10-29 |