| NPI | 1194713610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA09588) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: FL PA0003461) |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2019-08-05 |