| NPI | 1750864955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 13339650-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-69721) |
| 363AS0400X Physician Assistant, Surgical (Licence: MT MED-PAC-LIC-69721) | |
| Enumeration Date | 2018-09-13 |
| Last Update Date | 2023-08-04 |