| NPI | 1629385950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8713908-1206) |
| Additional Taxonomies | 207X00000X Orthopaedic Surgery (Licence: UT 8713908-1206) |
| 363AS0400X Physician Assistant Surgical (Licence: PA MA054520) | |
| Enumeration Date | 2010-09-08 |
| Last Update Date | 2020-02-12 |