| NPI | 1578800819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 5259) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA08298) |
| Enumeration Date | 2013-01-07 |
| Last Update Date | 2021-07-26 |