| NPI | 1538311691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 379299-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 379299-1206) |
| Enumeration Date | 2008-10-21 |
| Last Update Date | 2018-03-21 |