| NPI | 1679580435 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA06442) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601004142) |
| 363A00000X Physician Assistant (Licence: TX PA06442) | |
| Enumeration Date | 2006-08-02 |
| Last Update Date | 2023-06-01 |