| NPI | 1578117131 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: TX PA14884) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: KY PA2534) |
| Enumeration Date | 2019-07-31 |
| Last Update Date | 2021-09-10 |