| NPI | 1811063647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA16710) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 1591) |
| 363A00000X Physician Assistant (Licence: IL 085005428) | |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA 9106393) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TN PA0000001591) | |
| Enumeration Date | 2006-11-24 |
| Last Update Date | 2023-10-17 |