| NPI | 1649367590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2593) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: SC A434FP) |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2020-03-10 |