| NPI | 1598019069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA09400) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: ID PA-1011) |
| Enumeration Date | 2012-11-05 |
| Last Update Date | 2020-04-27 |