| NPI | 1780675967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA06802) |
| Additional Taxonomies | 146L00000X Emergency Medical Technician, Paramedic (Licence: TX 45448) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NE 020202111) | |
| 363A00000X Physician Assistant (Licence: CO PA.0005767) | |
| 363A00000X Physician Assistant (Licence: TX 1092900) | |
| Enumeration Date | 2005-11-04 |
| Last Update Date | 2022-09-20 |