| NPI | 1457767527 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TX PA10327) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004661) |
| Enumeration Date | 2014-07-09 |
| Last Update Date | 2024-01-18 |