| NPI | 1205875564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA06430) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 55358631206) |
| Enumeration Date | 2006-06-05 |
| Last Update Date | 2021-08-16 |