| NPI | 1972083137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TX PA12454) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2018-08-17 |
| Last Update Date | 2019-05-15 |