| NPI | 1386018778 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA12693) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2015-11-23 |
| Last Update Date | 2020-08-07 |