| NPI | 1023014263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TN PA0000001212) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA001212) |
| Enumeration Date | 2005-06-22 |
| Last Update Date | 2016-02-18 |