| NPI | 1982121364 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55083) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA14149) |
| Enumeration Date | 2017-08-25 |
| Last Update Date | 2023-09-04 |