| NPI | 1598366791 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 10302) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant |
| 363A00000X Physician Assistant (Licence: TX 1353) | |
| 363AM0700X Physician Assistant, Medical (Licence: PR 1353-P.A.) | |
| Enumeration Date | 2020-11-04 |
| Last Update Date | 2024-04-25 |