| NPI | 1649610825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10403064-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA1443) |
| Enumeration Date | 2013-07-02 |
| Last Update Date | 2025-03-19 |