| NPI | 1356458764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA08152) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 002075) |
| 363AM0700X Physician Assistant, Medical (Licence: TX PA08152) | |
| 363AM0700X Physician Assistant, Medical (Licence: NY 002075) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA08152) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 002075) | |
| Enumeration Date | 2006-08-23 |
| Last Update Date | 2019-08-02 |