| NPI | 1619091287 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 0757) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA05209) |
| Enumeration Date | 2007-03-19 |
| Last Update Date | 2019-07-24 |