| NPI | 1659840957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA13624) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 1158127) |
| Enumeration Date | 2018-11-15 |
| Last Update Date | 2024-05-15 |