| NPI | 1649693540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 51415) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA08998) |
| Enumeration Date | 2014-01-28 |
| Last Update Date | 2016-07-21 |