| NPI | 1356832992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12090) |
| Additional Taxonomies | 208D00000X General Practice (Licence: TX Pending) |
| Enumeration Date | 2018-05-18 |
| Last Update Date | 2022-09-26 |