| NPI | 1194756668 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9104788) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA1096) |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2023-03-07 |