| NPI | 1235173543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX 9557601-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 9557601-1206) |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2024-11-12 |