| NPI | 1598862443 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 785) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA05343) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2019-10-10 |