| NPI | 1962595363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA02549) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004793) |
| Enumeration Date | 2006-09-30 |
| Last Update Date | 2019-12-16 |