| NPI | 1558745604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12762371-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11873) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2015-07-17 |
| Last Update Date | 2024-01-19 |