| NPI | 1255790796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA10504) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2016-02-12 |
| Last Update Date | 2019-08-23 |