| NPI | 1306312822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: TX PA12400) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TX TEMPORARY) |
| Enumeration Date | 2018-10-23 |
| Last Update Date | 2021-05-07 |