| NPI | 1417112103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA053453) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA18156) |
| Enumeration Date | 2008-07-23 |
| Last Update Date | 2025-04-24 |