| NPI | 1063406650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA01121) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX PA01121) |
| Enumeration Date | 2005-09-09 |
| Last Update Date | 2015-04-06 |