| NPI | 1821743642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA15272) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA15272) |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA15272) | |
| Enumeration Date | 2022-02-21 |
| Last Update Date | 2023-06-24 |