| NPI | 1902530835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA15992) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-07-15 |
| Last Update Date | 2024-02-23 |