| NPI | 1457819146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA14854) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA14854) |
| 363A00000X Physician Assistant (Licence: AL PA1417) | |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9111679) | |
| Enumeration Date | 2019-03-12 |
| Last Update Date | 2023-12-27 |