| NPI | 1124303334 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN PA3923) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: CA PA21940) |
| 363AM0700X Physician Assistant, Medical (Licence: CA PA21940) | |
| Enumeration Date | 2011-10-19 |
| Last Update Date | 2020-08-13 |