| NPI | 1902320468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 4403) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 3608) |
| 363A00000X Physician Assistant (Licence: TX PA11404) | |
| Enumeration Date | 2017-07-26 |
| Last Update Date | 2021-03-17 |