| NPI | 1487747515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: UT 6717503-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 1003) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2017-03-30 |