| NPI | 1770880130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7898193-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: UT 7898193-1206) |
| Enumeration Date | 2011-02-22 |
| Last Update Date | 2016-01-11 |