| NPI | 1922092147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7729912-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1047583) |
| Enumeration Date | 2005-09-02 |
| Last Update Date | 2021-11-23 |