| NPI | 1518453976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 10961171-1206) |
| Enumeration Date | 2018-07-09 |
| Last Update Date | 2023-01-09 |