| NPI | 1356040042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA18209) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 029543) |
| 363AM0700X Physician Assistant, Medical (Licence: TX PA18209) | |
| Enumeration Date | 2023-03-01 |
| Last Update Date | 2024-12-23 |