| NPI | 1891730008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9105645) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA01537) |
| Enumeration Date | 2006-06-19 |
| Last Update Date | 2014-09-04 |