| NPI | 1750574372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA05297) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX PA05297) |
| Enumeration Date | 2007-08-27 |
| Last Update Date | 2019-09-26 |