| NPI | 1386876761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7426326-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 7426326-1206) |
| 363AM0700X Physician Assistant, Medical (Licence: UT 7426326-8906) | |
| Enumeration Date | 2009-08-18 |
| Last Update Date | 2022-12-11 |