NPI | 1700394731 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA19304) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C07159) |
Enumeration Date | 2018-01-11 |
Last Update Date | 2025-07-21 |