| NPI | 1992040562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA08811) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 6685) |
| Enumeration Date | 2012-12-07 |
| Last Update Date | 2022-03-31 |