| NPI | 1457860934 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 9185504-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: UT 9185504-1206) |
| Enumeration Date | 2017-09-27 |
| Last Update Date | 2023-11-27 |