| NPI | 1700458445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 13516808-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2021-07-13 |
| Last Update Date | 2026-05-29 |