| NPI | 1952859852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10074702-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 10074702-1206) |
| Enumeration Date | 2016-09-20 |
| Last Update Date | 2023-05-02 |