| NPI | 1619962388 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX 04829) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA04829) |
| 363AM0700X Physician Assistant, Medical (Licence: TX PA 04829) | |
| Enumeration Date | 2005-09-19 |
| Last Update Date | 2025-02-11 |