| NPI | 1407240484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX 1011811) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| Enumeration Date | 2015-03-26 |
| Last Update Date | 2022-10-18 |