| NPI | 1639403645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TN 1879) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003139) |
| Enumeration Date | 2009-09-23 |
| Last Update Date | 2018-01-29 |