| NPI | 1588625610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12113) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004130) |
| 363A00000X Physician Assistant (Licence: WA PA10004059) | |
| 363A00000X Physician Assistant (Licence: AK 130569) | |
| 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-65937) | |
| Enumeration Date | 2006-03-29 |
| Last Update Date | 2021-04-30 |