| NPI | 1356882575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA11282) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-03-20 |
| Last Update Date | 2022-01-25 |