| NPI | 1912110834 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA13691) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA3469) |
| Enumeration Date | 2007-05-07 |
| Last Update Date | 2022-10-20 |