| NPI | 1609253962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: UT 9317717-1206) |
| Additional Taxonomies | 261QP2300X Clinic/Center Primary Care (Licence: UT 9317717-1206) |
| Enumeration Date | 2015-05-06 |
| Last Update Date | 2025-07-23 |