| NPI | 1942416292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA11409) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2007-05-15 |
| Last Update Date | 2019-03-13 |