| NPI | 1811173107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA09310) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: TX PA009310) |
| 363AS0400X Physician Assistant Surgical (Licence: TX PA009310) | |
| Enumeration Date | 2008-01-16 |
| Last Update Date | 2024-02-22 |