| NPI | 1760594378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 709) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA00170) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2019-01-07 |