| NPI | 1619418472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12023191-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA1840) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2017-03-13 |
| Last Update Date | 2021-09-30 |