| NPI | 1942296397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA06385) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9103972) |
| 363A00000X Physician Assistant (Licence: IL 085-002417) | |
| 363A00000X Physician Assistant (Licence: KS 1500935) | |
| Enumeration Date | 2005-09-21 |
| Last Update Date | 2021-12-28 |