| NPI | 1366819575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 9507174-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 9507174-8002) |
| Enumeration Date | 2015-08-24 |
| Last Update Date | 2016-09-19 |