| NPI | 1548396096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 812) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA02240) |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2021-09-30 |