| NPI | 1730691429 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 1753) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA11564) |
| Enumeration Date | 2017-11-02 |
| Last Update Date | 2021-07-14 |