| NPI | 1457647414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MS PA00167) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 2011024428) |
| 363A00000X Physician Assistant (Licence: TN 1987) | |
| Enumeration Date | 2011-06-28 |
| Last Update Date | 2013-03-19 |