| NPI | 1619970647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 6183824-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 2838) |
| Enumeration Date | 2005-05-23 |
| Last Update Date | 2018-11-13 |