| NPI | 1700278256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12084) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 3282) |
| Enumeration Date | 2015-02-20 |
| Last Update Date | 2020-10-29 |