| NPI | 1710350665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07613) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 001007613) |
| 363A00000X Physician Assistant (Licence: TX PA11094) | |
| Enumeration Date | 2015-11-01 |
| Last Update Date | 2023-01-17 |