| NPI | 1801223425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 9557562-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11474) |
| Enumeration Date | 2013-09-27 |
| Last Update Date | 2022-07-21 |