| NPI | 1962707869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA056076) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 7884895-1206) |
| Enumeration Date | 2011-01-24 |
| Last Update Date | 2019-07-23 |