| NPI | 1376853036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 352301-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 0003660) |
| 363A00000X Physician Assistant (Licence: KS 15-01671) | |
| Enumeration Date | 2010-10-15 |
| Last Update Date | 2015-11-24 |