| NPI | 1720486863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA11189) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 017877-1) |
| Enumeration Date | 2014-12-05 |
| Last Update Date | 2017-10-03 |