| NPI | 1215213863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2857) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA08009) |
| 363A00000X Physician Assistant (Licence: GA 6189) | |
| Enumeration Date | 2011-10-27 |
| Last Update Date | 2019-01-02 |