| NPI | 1578962700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 9146633-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2014-08-13 |
| Last Update Date | 2024-08-01 |