| NPI | 1063505857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 1497) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 104187) |
| 363AS0400X Physician Assistant, Surgical (Licence: TN 1497) | |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2022-10-06 |