| NPI | 1164509881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA01612) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OK 841) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2015-10-15 |