| NPI | 1720413974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7428364-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 7428364-8906) |
| 133V00000X Dietitian, Registered (Licence: UT 7428364-4901) | |
| Enumeration Date | 2013-09-06 |
| Last Update Date | 2026-04-23 |