| NPI | 1588642524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA09755) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA 60205803) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 5650) | |
| Enumeration Date | 2006-01-09 |
| Last Update Date | 2023-01-26 |