| NPI | 1417201419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: UT 9144918-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: UT 9144918-8906) |
| Enumeration Date | 2012-10-30 |
| Last Update Date | 2023-11-27 |