| NPI | 1184107401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12240) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX 668285) |
| Enumeration Date | 2018-09-12 |
| Last Update Date | 2024-01-02 |