| NPI | 1790212629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: UT 12917809-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0005119) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2017-05-23 |
| Last Update Date | 2022-08-16 |