| NPI | 1396207346 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12716) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IL 085007422) |
| Enumeration Date | 2019-04-01 |
| Last Update Date | 2019-10-30 |