| NPI | 1649975012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX TX19753) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: CT 6138) | |
| Enumeration Date | 2023-04-04 |
| Last Update Date | 2026-07-22 |