| NPI | 1174190094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX 14507) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 10732) |
| Enumeration Date | 2021-06-09 |
| Last Update Date | 2024-10-24 |