| NPI | 1528463379 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA13355) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5904) |
| Enumeration Date | 2014-10-22 |
| Last Update Date | 2025-02-14 |