| NPI | 1689645129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 101650-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NV PAC656) |
| Enumeration Date | 2006-02-01 |
| Last Update Date | 2014-10-28 |