NPI | 1972513364 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: LA 200155) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA04743) |
Enumeration Date | 2006-08-08 |
Last Update Date | 2019-02-28 |