| NPI | 1336540749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA17836) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601007114) |
| Enumeration Date | 2014-09-05 |
| Last Update Date | 2024-07-08 |