| NPI | 1760420590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 55397531206) |
| Enumeration Date | 2006-06-03 |
| Last Update Date | 2011-12-12 |