| NPI | 1174523526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA02398) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C03055) |
| Enumeration Date | 2005-07-28 |
| Last Update Date | 2007-07-08 |