| NPI | 1750370508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004898) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 5177317-1206) |
| Enumeration Date | 2005-10-14 |
| Last Update Date | 2016-12-14 |