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Individual
UY NGO
Active
Individual
UY NGO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA02900
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
143771702
—
TX
05
—
143771703
—
TX
05
—
143771704
—
TX
01
—
1669552071
BCBS
TX
01
—
P01124906
RR MEDICARE
TX
Enumeration date
10/17/2006
Last updated
02/15/2013
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