| NPI | 1588205538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA18179) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 146627) |
| 363AM0700X Physician Assistant, Medical (Licence: AK 146627) | |
| Enumeration Date | 2019-10-01 |
| Last Update Date | 2024-11-01 |