| NPI | 1417942657 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: TN PA1617) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 110001634) |
| Enumeration Date | 2005-09-14 |
| Last Update Date | 2016-08-04 |