| NPI | 1275012379 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12148) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 008863) |
| Enumeration Date | 2018-08-09 |
| Last Update Date | 2022-03-15 |