| NPI | 1639541717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA 1127062) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX 1127062) |
| Enumeration Date | 2015-10-28 |
| Last Update Date | 2019-08-19 |