| NPI | 1194701920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 102950-1206) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 102950-1206) |
| Enumeration Date | 2005-12-22 |
| Last Update Date | 2021-09-14 |