| NPI | 1790838621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC PA1575) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA10819) |
| 363A00000X Physician Assistant (Licence: NC 0010-00631) | |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2021-08-20 |