| NPI | 1174215552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA17339) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 6085) |
| Enumeration Date | 2023-05-23 |
| Last Update Date | 2024-09-09 |