| NPI | 1063408599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA07421) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 0000000) |
| 363AM0700X Physician Assistant, Medical (Licence: TX 000000000) | |
| Enumeration Date | 2005-09-20 |
| Last Update Date | 2014-09-16 |