| NPI | 1104828185 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA02984) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA02984) |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA02984) | |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2013-10-21 |