| NPI | 1518500115 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JESSICA MCBAIN Credentialing Specialist 972-489-8535 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| Enumeration Date | 2019-10-26 |
| Last Update Date | 2019-10-26 |