| NPI | 1730848631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 13006847-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2021-12-08 |
| Last Update Date | 2022-12-15 |