| NPI | 1790115798 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA08503) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA08503) |
| 363A00000X Physician Assistant (Licence: OR PA181350) | |
| Enumeration Date | 2013-11-13 |
| Last Update Date | 2023-06-02 |