| NPI | 1700326493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 1138811) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA13022) |
| 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-127922) | |
| Enumeration Date | 2017-03-01 |
| Last Update Date | 2024-04-23 |