| NPI | 1568100501 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7355058-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2022-05-20 |
| Last Update Date | 2023-06-23 |