| NPI | 1548709009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA11199) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 3592) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2017-02-16 |
| Last Update Date | 2021-06-01 |