| NPI | 1730762444 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA14564) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX 14564) |
| Enumeration Date | 2021-04-30 |
| Last Update Date | 2021-09-23 |