| NPI | 1255685202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MS PA00585) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2220) |
| Enumeration Date | 2012-10-30 |
| Last Update Date | 2021-09-10 |