| NPI | 1215077797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA01587) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 103572) |
| Enumeration Date | 2007-02-07 |
| Last Update Date | 2015-02-12 |