| NPI | 1407007412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 11918893-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 4253) |
| Enumeration Date | 2008-10-08 |
| Last Update Date | 2023-03-07 |