| NPI | 1194313270 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA14220) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA14220) | |
| Enumeration Date | 2021-01-05 |
| Last Update Date | 2021-10-19 |