| NPI | 1669588679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA07852) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA001065) |
| Enumeration Date | 2006-08-22 |
| Last Update Date | 2022-07-21 |