| NPI | 1467252155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 14205573-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID 6071156) |
| Enumeration Date | 2025-03-13 |
| Last Update Date | 2026-02-24 |