| NPI | 1952306847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 2912) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA07352) |
| 363AM0700X Physician Assistant, Medical (Licence: WI 1702) | |
| Enumeration Date | 2005-06-16 |
| Last Update Date | 2018-08-22 |