| NPI | 1588671077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2018016912) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA08119) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2019-08-20 |