| NPI | 1053388132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2931) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0001602) |
| Enumeration Date | 2006-03-07 |
| Last Update Date | 2021-09-22 |