| NPI | 1396018057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TN 2102) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TN PA02102) |
| Enumeration Date | 2012-02-10 |
| Last Update Date | 2019-08-23 |