| NPI | 1972119964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA13898) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX Temp) |
| 363AM0700X Physician Assistant, Medical (Licence: TX Temp) | |
| Enumeration Date | 2020-09-16 |
| Last Update Date | 2020-10-28 |