| NPI | 1992845549 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 102011-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 1989) |
| Enumeration Date | 2007-02-06 |
| Last Update Date | 2018-03-17 |