| NPI | 1447660337 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8001227-1206) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: UT 8001227-4810) |
| 363AS0400X Physician Assistant, Surgical (Licence: UT 8001227-1206) | |
| Enumeration Date | 2014-05-01 |
| Last Update Date | 2023-06-27 |