| NPI | 1700401759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: UT 5758005-1206) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 363A00000X Physician Assistant (Licence: UT 5758005-1206) | |
| Enumeration Date | 2020-06-15 |
| Last Update Date | 2022-02-09 |