| NPI | 1750407623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA02487) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601001174) |
| Enumeration Date | 2007-03-22 |
| Last Update Date | 2017-01-25 |