| NPI | 1174932107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN PA0000002411) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TN 2411) |
| Enumeration Date | 2014-08-04 |
| Last Update Date | 2021-09-22 |