| NPI | 1538250626 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 1432) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003724) |
| Enumeration Date | 2006-09-27 |
| Last Update Date | 2022-08-09 |