| NPI | 1396289799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10174452-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: UT 10174452-1206) |
| Enumeration Date | 2016-12-05 |
| Last Update Date | 2021-09-14 |