| NPI | 1164016663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA19895) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX PA19895) |
| Enumeration Date | 2021-02-24 |
| Last Update Date | 2026-06-16 |