| NPI | 1104163104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA08205) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2013-01-10 |
| Last Update Date | 2013-06-07 |