| NPI | 1871960823 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 9515470) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 9515470-1206) |
| Enumeration Date | 2015-08-25 |
| Last Update Date | 2024-05-20 |