| NPI | 1427308899 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 5993982-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 01) |
| Enumeration Date | 2012-09-13 |
| Last Update Date | 2021-08-30 |