| NPI | 1760557946 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA05103) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX PA05103) |
| 363AM0700X Physician Assistant, Medical (Licence: TX PA05103) | |
| Enumeration Date | 2006-11-22 |
| Last Update Date | 2024-03-22 |