| NPI | 1790014447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AR PA-843) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA06492) |
| Enumeration Date | 2009-12-09 |
| Last Update Date | 2021-01-26 |