| NPI | 1366754574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TN 1850) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 1850) |
| 363AS0400X Physician Assistant Surgical (Licence: TN 1850) | |
| Enumeration Date | 2010-07-06 |
| Last Update Date | 2020-02-07 |