| NPI | 1578279410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: UT 78900791206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant Surgical (Licence: UT 7890079-1206) | |
| Enumeration Date | 2023-01-24 |
| Last Update Date | 2023-10-09 |