| NPI | 1033173851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: TN PA5616) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 103770) |
| 363AS0400X Physician Assistant Surgical (Licence: NC 0001-03770) | |
| Enumeration Date | 2006-04-17 |
| Last Update Date | 2024-02-05 |