| NPI | 1649701988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA220492) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA11201) |
| Enumeration Date | 2017-03-27 |
| Last Update Date | 2024-10-01 |