| NPI | 1720098411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: TX PA02660) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA02660) |
| 363AM0700X Physician Assistant Medical (Licence: AR PT-1120) | |
| Enumeration Date | 2006-08-08 |
| Last Update Date | 2023-03-10 |