| NPI | 1447450556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8401684-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA pa19180) |
| Enumeration Date | 2007-07-18 |
| Last Update Date | 2025-11-19 |