| NPI | 1649502048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 1815) |
| 363AS0400X Physician Assistant, Surgical (Licence: TN 1815) | |
| Enumeration Date | 2010-02-10 |
| Last Update Date | 2024-04-17 |