| NPI | 1750634507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 9096169-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 016175) |
| Enumeration Date | 2012-10-17 |
| Last Update Date | 2023-02-07 |