| NPI | 1295764769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN PA526) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 2512) |
| 363AM0700X Physician Assistant, Medical (Licence: CA 21539) | |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2023-04-20 |