| NPI | 1104301852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12348) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX Temporary) |
| Enumeration Date | 2018-09-28 |
| Last Update Date | 2022-06-29 |