| NPI | 1932169356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 5395) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA02760) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 101930) | |
| Enumeration Date | 2006-03-28 |
| Last Update Date | 2021-06-22 |