| NPI | 1407449960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12385) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA14490) |
| 363A00000X Physician Assistant (Licence: TN 5173) | |
| Enumeration Date | 2021-02-16 |
| Last Update Date | 2023-07-05 |