| NPI | 1932674355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 11038201-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2018-10-12 |
| Last Update Date | 2025-03-25 |