| NPI | 1972901650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TX PA09502) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OK 2585) |
| Enumeration Date | 2014-12-12 |
| Last Update Date | 2021-03-10 |