| NPI | 1710912076 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA05565) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 1228) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2021-01-11 |