| NPI | 1629512645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA19181) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10002175A) |
| Enumeration Date | 2016-12-09 |
| Last Update Date | 2025-08-15 |