| NPI | 1457656902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2153) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-02971) |
| Enumeration Date | 2011-01-13 |
| Last Update Date | 2017-03-07 |