| NPI | 1619460938 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TX PA13372) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA6600) |
| 363AS0400X Physician Assistant Surgical (Licence: MA PA6600) | |
| Enumeration Date | 2018-06-12 |
| Last Update Date | 2021-12-21 |