| NPI | 1922311646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX 1091571) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2010-07-22 |
| Last Update Date | 2017-02-13 |