| NPI | 1730411455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8072567-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 4598) |
| Enumeration Date | 2010-02-04 |
| Last Update Date | 2022-05-25 |