| NPI | 1922774215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 11289480-1206) |
| Additional Taxonomies | 225100000X Physical Therapist |
| Enumeration Date | 2021-08-18 |
| Last Update Date | 2026-07-07 |