| NPI | 1942209119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA03903) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA2493) |
| Enumeration Date | 2005-07-19 |
| Last Update Date | 2023-05-24 |