| NPI | 1588171060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 9147996-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2018-01-05 |
| Last Update Date | 2022-04-29 |