| NPI | 1790093201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 258981-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 8156) |
| Enumeration Date | 2010-09-17 |
| Last Update Date | 2024-12-08 |