| NPI | 1073795365 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA00335) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY PA887) |
| 363AM0700X Physician Assistant, Medical (Licence: TX 00335) | |
| Enumeration Date | 2007-11-29 |
| Last Update Date | 2024-04-24 |