| NPI | 1831646843 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 13933798-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA56261) |
| Enumeration Date | 2016-09-07 |
| Last Update Date | 2025-12-09 |