| NPI | 1760100127 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA18489) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: TX PA18489) |
| Enumeration Date | 2022-08-19 |
| Last Update Date | 2024-12-03 |