| NPI | 1215943212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 1083) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TN 1083) |
| 363AM0700X Physician Assistant Medical (Licence: TN 1083) | |
| Enumeration Date | 2006-07-31 |
| Last Update Date | 2011-02-23 |