| NPI | 1417468992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3967) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant Surgical (Licence: TX PA11681) | |
| Enumeration Date | 2017-10-23 |
| Last Update Date | 2021-07-22 |