| NPI | 1376016766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12573354-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 172V00000X Community Health Worker | |
| Enumeration Date | 2019-01-08 |
| Last Update Date | 2022-01-18 |