| NPI | 1891506713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA19258) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA19258) |
| Enumeration Date | 2025-01-20 |
| Last Update Date | 2025-08-09 |