| NPI | 1215661541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX PA16348) |
| Enumeration Date | 2022-07-12 |
| Last Update Date | 2025-08-04 |