NPI | 1679087399 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: UT 8294013-1206) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 8294013-126) |
Enumeration Date | 2017-11-17 |
Last Update Date | 2021-11-17 |