| NPI | 1770034761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 10098970-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: UT 10098970-1206) |
| Enumeration Date | 2016-10-14 |
| Last Update Date | 2019-01-31 |