| NPI | 1649560764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 6306798-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY PA630) |
| Enumeration Date | 2011-04-11 |
| Last Update Date | 2020-05-07 |