| NPI | 1720385156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2150) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA07086) |
| Enumeration Date | 2011-02-21 |
| Last Update Date | 2014-09-05 |