| NPI | 1174815138 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 6089) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2573) |
| Enumeration Date | 2011-05-10 |
| Last Update Date | 2017-05-03 |