| NPI | 1831255298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TX PA11207) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WA PA10004798) |
| 363AS0400X Physician Assistant Surgical (Licence: WA PA10004798) | |
| Enumeration Date | 2006-12-29 |
| Last Update Date | 2018-10-02 |