| NPI | 1134137169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TN NCCPA Cert Number) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN TN573) |
| Enumeration Date | 2006-08-04 |
| Last Update Date | 2007-07-08 |