| NPI | 1114956604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA04768) |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA04768) | |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2017-04-12 |