| NPI | 1700108685 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA10711) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA10711) | |
| Enumeration Date | 2010-02-19 |
| Last Update Date | 2021-03-29 |