| NPI | 1881001766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA10164) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MO 2014023862) |
| Enumeration Date | 2014-07-12 |
| Last Update Date | 2015-12-03 |