| NPI | 1538423322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2192) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003983) |
| Enumeration Date | 2012-06-27 |
| Last Update Date | 2013-12-11 |