| NPI | 1336301480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA09255) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX 050802360) |
| Enumeration Date | 2008-06-30 |
| Last Update Date | 2016-05-18 |