| NPI | 1811554694 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12056611-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2019-05-28 |
| Last Update Date | 2023-03-31 |