| NPI | 1659701696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2436) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004691) |
| Enumeration Date | 2013-11-12 |
| Last Update Date | 2018-06-04 |