| NPI | 1316729643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA17675) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2023-10-20 |
| Last Update Date | 2025-01-29 |