| NPI | 1487964110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA08299) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA 9105622) |
| 363AM0700X Physician Assistant, Medical (Licence: TX PA08299) | |
| Enumeration Date | 2010-10-15 |
| Last Update Date | 2022-11-16 |