| NPI | 1972620417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 287096-1206) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 287096-1206) |
| Enumeration Date | 2007-03-22 |
| Last Update Date | 2023-03-07 |