| NPI | 1639505779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 9372775-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9107450) |
| Enumeration Date | 2013-09-20 |
| Last Update Date | 2016-04-22 |