| NPI | 1568786838 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10001575A) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA04676) |
| 363AM0700X Physician Assistant, Medical (Licence: CO 3196) | |
| Enumeration Date | 2010-03-16 |
| Last Update Date | 2024-01-19 |