| NPI | 1649941402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA14972) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA 328722) |
| Enumeration Date | 2021-09-22 |
| Last Update Date | 2025-06-11 |