| NPI | 1912961897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA13272) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: LA A10176) |
| 363AS0400X Physician Assistant, Surgical (Licence: TN PA2181) | |
| Enumeration Date | 2006-04-17 |
| Last Update Date | 2020-01-02 |