| NPI | 1306140454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA16044) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2011-01-04 |
| Last Update Date | 2025-01-24 |