| NPI | 1821627746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 11856179-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 57989) |
| Enumeration Date | 2020-04-02 |
| Last Update Date | 2023-01-23 |