| NPI | 1710496047 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10982649-1206) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AZ 6854) |
| Enumeration Date | 2017-09-29 |
| Last Update Date | 2022-07-21 |