| NPI | 1407393705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9301) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 3265) |
| Enumeration Date | 2017-01-24 |
| Last Update Date | 2024-03-01 |