| NPI | 1780114348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10420324-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 4778) |
| Enumeration Date | 2017-06-15 |
| Last Update Date | 2024-02-06 |