| NPI | 1124163894 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA03455) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2022-06-01 |