| NPI | 1760737357 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA00376) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9103383) |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA00376) | |
| Enumeration Date | 2012-07-19 |
| Last Update Date | 2023-04-04 |