| NPI | 1740838507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA13174) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX PA13174) |
| Enumeration Date | 2019-08-26 |
| Last Update Date | 2022-01-04 |