| NPI | 1639318645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 4854) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA01451) |
| Enumeration Date | 2009-02-13 |
| Last Update Date | 2024-01-05 |