| NPI | 1558939017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TN 4611) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110007913) |
| 363A00000X Physician Assistant (Licence: TN 4611) | |
| 363AM0700X Physician Assistant Medical (Licence: VA 0110007913) | |
| Enumeration Date | 2021-06-11 |
| Last Update Date | 2021-09-22 |