| NPI | 1770564429 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 13877149-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV pa1083) |
| 363A00000X Physician Assistant (Licence: UT 13877149-8906) | |
| Enumeration Date | 2005-11-09 |
| Last Update Date | 2024-07-23 |