| NPI | 1619163425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA06090) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: FL PA 9104123) |
| Enumeration Date | 2007-09-15 |
| Last Update Date | 2012-02-02 |