| NPI | 1205001237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA07054) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012510) |
| Enumeration Date | 2008-04-30 |
| Last Update Date | 2012-09-13 |