| NPI | 1588773204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 6712836-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 18507) |
| Enumeration Date | 2006-08-29 |
| Last Update Date | 2011-04-19 |