| NPI | 1790282242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA13422) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2018-0023) |
| Enumeration Date | 2018-04-11 |
| Last Update Date | 2023-09-25 |