| NPI | 1629694807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 11995359-1206) |
| Additional Taxonomies | 207X00000X Orthopaedic Surgery (Licence: UT 11995359-1206) |
| 208100000X Physical Medicine & Rehabilitation (Licence: UT 11995359-1206) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-06-23 |
| Last Update Date | 2025-10-22 |