| NPI | 1780269571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA15505) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: AZ 8376) |
| Enumeration Date | 2021-03-12 |
| Last Update Date | 2022-03-30 |