| NPI | 1609253962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 9317717-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 9317717-1206) |
| Enumeration Date | 2015-05-06 |
| Last Update Date | 2026-06-16 |