| NPI | 1851855258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1883) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA12578) |
| Enumeration Date | 2019-01-30 |
| Last Update Date | 2020-09-09 |