| NPI | 1598749111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA05995) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601001623) |
| Enumeration Date | 2005-12-06 |
| Last Update Date | 2020-08-20 |