| NPI | 1740415256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 1087691) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA09207) |
| Enumeration Date | 2009-05-28 |
| Last Update Date | 2019-12-04 |