| NPI | 1629046370 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA10523) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110001541) |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2016-12-09 |