| NPI | 1811469604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 11690304-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 11690304-1206) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2018-12-18 |
| Last Update Date | 2024-03-12 |