| NPI | 1780103903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: UT 10495614-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 10495614-1206) |
| Enumeration Date | 2017-09-19 |
| Last Update Date | 2021-11-17 |