| NPI | 1255802112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12507) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA56385) |
| Enumeration Date | 2018-12-17 |
| Last Update Date | 2021-07-27 |