| NPI | 1962806190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 9560215-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 9560215-1206) |
| 363A00000X Physician Assistant (Licence: NM PA2014-0080) | |
| 363A00000X Physician Assistant (Licence: NV PA2528) | |
| 363AM0700X Physician Assistant, Medical (Licence: NV PA2528) | |
| Enumeration Date | 2014-10-17 |
| Last Update Date | 2023-03-29 |