| NPI | 1891894630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AR PA-520) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA03035) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2013-10-28 |