| NPI | 1376662213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA06210) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX 1057857) |
| Enumeration Date | 2007-03-29 |
| Last Update Date | 2023-08-18 |