| NPI | 1871555300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA04583) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX PA04583) |
| 363A00000X Physician Assistant (Licence: TX PA04583) | |
| Enumeration Date | 2006-04-03 |
| Last Update Date | 2012-11-26 |