| NPI | 1396745758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA03575) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 1500540) |
| 363A00000X Physician Assistant (Licence: MN 10117) | |
| Enumeration Date | 2005-07-28 |
| Last Update Date | 2015-03-11 |