| NPI | 1538150206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WY 278) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA07484) |
| Enumeration Date | 2005-11-02 |
| Last Update Date | 2024-04-01 |