| NPI | 1245699479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA11448) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9109341) |
| Enumeration Date | 2016-02-16 |
| Last Update Date | 2023-03-27 |