| NPI | 1306807292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 1906) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50000610) |
| Enumeration Date | 2006-03-30 |
| Last Update Date | 2018-11-28 |