| NPI | 1609889252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 3745751206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 374575-8906) |
| Enumeration Date | 2006-08-14 |
| Last Update Date | 2022-02-17 |