| NPI | 1720315252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: UT 372835-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 372835-1206) |
| Enumeration Date | 2009-11-04 |
| Last Update Date | 2019-09-05 |