| NPI | 1134631716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA11670) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PATemp) |
| Enumeration Date | 2017-11-03 |
| Last Update Date | 2026-03-20 |