| NPI | 1063785681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 312368) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA09803) |
| Enumeration Date | 2012-02-13 |
| Last Update Date | 2021-09-10 |