| NPI | 1396011490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 6098807-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA0240) |
| Enumeration Date | 2012-03-22 |
| Last Update Date | 2017-03-21 |