| NPI | 1659702504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102775) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA04093) |
| Enumeration Date | 2013-12-03 |
| Last Update Date | 2014-01-03 |