| NPI | 1356792360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 9614663-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 53532) |
| Enumeration Date | 2016-06-30 |
| Last Update Date | 2018-03-17 |