| NPI | 1083976948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004319) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2175) |
| Enumeration Date | 2012-06-15 |
| Last Update Date | 2015-09-23 |