| NPI | 1629148440 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA05263) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10005117) |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA10005117) | |
| Enumeration Date | 2006-11-09 |
| Last Update Date | 2022-04-29 |