| NPI | 1477013381 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TN 3764) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA0000003764) |
| Enumeration Date | 2019-03-25 |
| Last Update Date | 2019-07-26 |