| NPI | 1336506153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2993) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110010568) |
| Enumeration Date | 2016-01-25 |
| Last Update Date | 2025-10-10 |