| NPI | 1134875669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA15396) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA8639) |
| Enumeration Date | 2022-02-23 |
| Last Update Date | 2023-08-03 |