| NPI | 1780658930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA04481) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK OK1740) |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2013-02-13 |