| NPI | 1033173851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 103770) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0001-03770) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 103770) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TN PA5616) | |
| Enumeration Date | 2006-04-17 |
| Last Update Date | 2025-09-15 |