| NPI | 1871982124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MA PA8660) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: TX PAT) |
| 363AM0700X Physician Assistant Medical (Licence: MA MCS002361J) | |
| Enumeration Date | 2015-01-09 |
| Last Update Date | 2022-12-06 |