| NPI | 1689964819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA07012) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085008756) |
| 363A00000X Physician Assistant (Licence: NY 027617) | |
| 363A00000X Physician Assistant (Licence: WA PA61234695) | |
| 363A00000X Physician Assistant (Licence: CA PA66983) | |
| 363A00000X Physician Assistant (Licence: WI 875323) | |
| Enumeration Date | 2011-04-08 |
| Last Update Date | 2026-03-19 |