| NPI | 1720087273 |
|---|---|
| Other Name | NONE NONE NONE |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA05757) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 002796) |
| Enumeration Date | 2005-07-18 |
| Last Update Date | 2010-12-29 |