| NPI | 1760859300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 5539823-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 5539823-1206) |
| Enumeration Date | 2015-08-31 |
| Last Update Date | 2021-11-20 |