| NPI | 1609076926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10231439-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1077676) |
| Enumeration Date | 2007-07-24 |
| Last Update Date | 2018-03-17 |