| NPI | 1649428277 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TN 3434) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-01521) |
| 363A00000X Physician Assistant (Licence: TN 3434) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TN 3434) | |
| Enumeration Date | 2008-09-08 |
| Last Update Date | 2025-09-30 |