| NPI | 1780062372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: TX PA13221) |
| Enumeration Date | 2015-05-14 |
| Last Update Date | 2024-08-07 |