| NPI | 1023411592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 9150949-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 9150949-1206) |
| Enumeration Date | 2014-09-29 |
| Last Update Date | 2021-11-12 |