| NPI | 1568862852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX BP10086834) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9108266) |
| Enumeration Date | 2014-08-25 |
| Last Update Date | 2024-08-16 |