| NPI | 1164119038 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA18185) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA18185) |
| Enumeration Date | 2023-04-20 |
| Last Update Date | 2026-04-06 |