| NPI | 1053708875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 5010) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TN PA2766) |
| 363A00000X Physician Assistant (Licence: TN 2766) | |
| 363A00000X Physician Assistant (Licence: SC 5010) | |
| Enumeration Date | 2015-04-20 |
| Last Update Date | 2023-12-15 |