| NPI | 1639174170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA06723) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA10004055) |
| Enumeration Date | 2005-06-20 |
| Last Update Date | 2015-08-12 |