| NPI | 1396126173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA10102) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004974) |
| Enumeration Date | 2015-06-17 |
| Last Update Date | 2023-05-31 |