| NPI | 1295273480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN PA0000003218) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TN PA0000003218) |
| 363AM0700X Physician Assistant Medical (Licence: TN PA0000003218) | |
| Enumeration Date | 2017-02-07 |
| Last Update Date | 2024-02-05 |