| NPI | 1982626354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2022001110) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA00577) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2023-08-24 |