| NPI | 1407300767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA11394) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2016-08-04 |
| Last Update Date | 2022-11-09 |