| NPI | 1396704516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: AL PA398) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TN PA1217) |
| Enumeration Date | 2006-03-18 |
| Last Update Date | 2013-11-11 |