| NPI | 1114357381 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55130) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX 1115692) |
| Enumeration Date | 2013-11-25 |
| Last Update Date | 2020-09-25 |