| NPI | 1053010256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN PA6077) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA064392) |
| Enumeration Date | 2023-02-27 |
| Last Update Date | 2024-07-25 |