| NPI | 1558766675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: TX SA00602) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX 154210) |
| 363LX0001X Nurse Practitioner, Obstetrics & Gynecology (Licence: TX 154210) | |
| Enumeration Date | 2014-10-31 |
| Last Update Date | 2021-06-15 |