| NPI | 1790061919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8233732-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 5063) |
| 363AM0700X Physician Assistant, Medical (Licence: NM PA2012-0043) | |
| Enumeration Date | 2011-11-02 |
| Last Update Date | 2017-01-20 |