| NPI | 1689000903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA10697) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601006819) |
| Enumeration Date | 2013-09-18 |
| Last Update Date | 2025-05-08 |