| NPI | 1346811429 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10790675-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA2560) |
| Enumeration Date | 2021-07-08 |
| Last Update Date | 2023-02-21 |