| NPI | 1912122276 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA09612) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA15830) |
| Enumeration Date | 2007-04-13 |
| Last Update Date | 2022-05-03 |