| NPI | 1366453177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA11196) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.A10381.RX) |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2019-10-21 |