| NPI | 1134252620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TX PA02386) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TX PA02386) |
| Enumeration Date | 2007-03-13 |
| Last Update Date | 2007-07-08 |