| NPI | 1699330654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA12769) |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine (Licence: TX PA12769) |
| Enumeration Date | 2019-05-06 |
| Last Update Date | 2021-02-02 |