| NPI | 1740395094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1064) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA03539) |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2015-02-04 |