| NPI | 1720668411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12351455-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2021-04-08 |
| Last Update Date | 2021-12-28 |