| NPI | 1346884806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA14175) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA PA57420) |
| 261QU0200X Clinic/Center, Urgent Care (Licence: TX PA14175) | |
| Enumeration Date | 2019-10-29 |
| Last Update Date | 2021-09-08 |