| NPI | 1710369509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA14235) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 52596) |
| Enumeration Date | 2015-06-29 |
| Last Update Date | 2021-08-10 |