| NPI | 1124748223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA65099) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA18500) |
| Enumeration Date | 2022-08-30 |
| Last Update Date | 2025-03-31 |