| NPI | 1982154324 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06822) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA11517) |
| Enumeration Date | 2016-10-10 |
| Last Update Date | 2020-06-10 |