| NPI | 1487110474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AR PA-1154) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX pa13777) |
| Enumeration Date | 2019-02-14 |
| Last Update Date | 2023-05-01 |