| NPI | 1407256175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA10438) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05181) |
| 363A00000X Physician Assistant (Licence: GA 007528) | |
| Enumeration Date | 2014-08-29 |
| Last Update Date | 2018-07-05 |