| NPI | 1740140524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA19268) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA19268) |
| Enumeration Date | 2025-11-14 |
| Last Update Date | 2026-02-19 |