| NPI | 1689088460 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2823) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05060) |
| 363A00000X Physician Assistant (Licence: SC 3151) | |
| Enumeration Date | 2014-06-19 |
| Last Update Date | 2022-07-22 |