| NPI | 1740695899 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 081384) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA09172) |
| Enumeration Date | 2014-06-27 |
| Last Update Date | 2019-10-02 |