| NPI | 1083158307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA10659) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MS PA00388) |
| Enumeration Date | 2016-12-05 |
| Last Update Date | 2019-03-05 |