| NPI | 1962748871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA14624) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA PA64213) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-6404) | |
| Enumeration Date | 2012-12-20 |
| Last Update Date | 2024-10-28 |