| NPI | 1609406016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA14922) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 1165012) |
| Enumeration Date | 2020-01-24 |
| Last Update Date | 2022-08-02 |