| NPI | 1922420553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 11710873-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: UT 11710873-1206) | |
| Enumeration Date | 2014-01-16 |
| Last Update Date | 2023-12-04 |