| NPI | 1538101274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA13195) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA00852) |
| 363A00000X Physician Assistant (Licence: ID PA420) | |
| 363AS0400X Physician Assistant, Surgical (Licence: OR PA00852) | |
| Enumeration Date | 2006-06-10 |
| Last Update Date | 2024-02-13 |