| NPI | 1619252384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 6777964-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-03160) |
| 363A00000X Physician Assistant (Licence: NV PA1364) | |
| Enumeration Date | 2011-10-13 |
| Last Update Date | 2023-07-14 |