| NPI | 1881178580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7510295-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 7510295-1206) |
| 363AS0400X Physician Assistant, Surgical (Licence: UT 7510295-1206) | |
| Enumeration Date | 2018-09-18 |
| Last Update Date | 2025-03-20 |