| NPI | 1972022341 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12922) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.005213RX) |
| Enumeration Date | 2017-09-16 |
| Last Update Date | 2023-03-28 |