| NPI | 1386248292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12764152-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 8740) |
| 363AM0700X Physician Assistant, Medical (Licence: UT 12764152-1206) | |
| Enumeration Date | 2020-11-23 |
| Last Update Date | 2025-01-06 |