| NPI | 1366413874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 1316) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002182) |
| Enumeration Date | 2006-02-01 |
| Last Update Date | 2022-08-09 |