| NPI | 1619149028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 269) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA05588) |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA05588) | |
| Enumeration Date | 2008-03-25 |
| Last Update Date | 2020-12-18 |