| NPI | 1194594986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TN PA5822) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN PA5822) |
| Enumeration Date | 2023-12-21 |
| Last Update Date | 2024-02-23 |