| NPI | 1215057617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 368003-1206) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: UT 368003-2401) |
| Enumeration Date | 2007-03-30 |
| Last Update Date | 2016-05-10 |