| NPI | 1073524906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TN PA1719) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA1719) |
| 363A00000X Physician Assistant (Licence: FL PA9101707) | |
| 363AM0700X Physician Assistant, Medical (Licence: TN PA1719) | |
| Enumeration Date | 2006-08-09 |
| Last Update Date | 2018-01-29 |