| NPI | 1063430890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA02752) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 5166627-1206) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2025-03-31 |