| NPI | 1174579882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 1331) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN MT1404742) |
| Enumeration Date | 2006-05-25 |
| Last Update Date | 2007-07-08 |