| NPI | 1376604777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA06523) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA.200012.RX) |
| 363AS0400X Physician Assistant, Surgical (Licence: LA PA.200012.RX) | |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2022-02-07 |