| NPI | 1316196157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA06746) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 002160) |
| Enumeration Date | 2008-09-17 |
| Last Update Date | 2025-10-07 |