| NPI | 1619398021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8905020-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2014-01-02 |
| Last Update Date | 2024-06-07 |