| NPI | 1063797421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN PA0000004863) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA055284) |
| Enumeration Date | 2011-10-18 |
| Last Update Date | 2024-02-06 |