| NPI | 1649743196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 13121909-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA2070) |
| Enumeration Date | 2019-01-08 |
| Last Update Date | 2023-01-06 |