| NPI | 1912084120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA06447) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 011541) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2022-12-07 |