| NPI | 1104582790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA15078) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX TEMPORARY) |
| Enumeration Date | 2021-11-09 |
| Last Update Date | 2023-03-19 |