| NPI | 1801331467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12689705-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-06933) |
| 363AS0400X Physician Assistant, Surgical (Licence: UT 12689705-8906) | |
| Enumeration Date | 2017-01-05 |
| Last Update Date | 2022-10-26 |