| NPI | 1073936738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN PA3383) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9109353) |
| 363A00000X Physician Assistant (Licence: NY 017342) | |
| Enumeration Date | 2014-01-30 |
| Last Update Date | 2022-03-23 |