| NPI | 1790827251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7331309-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: GA 004935) |
| Enumeration Date | 2007-02-13 |
| Last Update Date | 2010-09-01 |