| NPI | 1033551502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05150) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA08531) |
| 363A00000X Physician Assistant (Licence: TN PA2530) | |
| Enumeration Date | 2013-07-24 |
| Last Update Date | 2014-10-15 |