| NPI | 1063295137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA17493) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-08-14 |
| Last Update Date | 2024-10-22 |