| NPI | 1790931210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 5000567-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 4827) |
| Enumeration Date | 2008-08-15 |
| Last Update Date | 2022-09-08 |