| NPI | 1578537320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TN PA1133) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TN PA0000001133) |
| 363A00000X Physician Assistant (Licence: TN PA1133) | |
| 363A00000X Physician Assistant (Licence: VA 0110001783) | |
| Enumeration Date | 2006-02-16 |
| Last Update Date | 2017-05-08 |