| NPI | 1700800679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 739) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 093064) |
| 363AM0700X Physician Assistant, Medical (Licence: TX PA02151) | |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2018-08-14 |