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 |