| NPI | 1720138365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA05061) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2018-0024) |
| Enumeration Date | 2007-01-12 |
| Last Update Date | 2023-02-15 |