| NPI | 1508994104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 965) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA05197) |
| Enumeration Date | 2007-03-02 |
| Last Update Date | 2011-06-21 |