| NPI | 1770072514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA14899) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9110979) |
| Enumeration Date | 2018-05-08 |
| Last Update Date | 2023-10-25 |