| NPI | 1528491735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 8695219-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 86952191206) |
| Enumeration Date | 2013-08-12 |
| Last Update Date | 2024-07-09 |