| NPI | 1689937971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 6014) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC474) |
| 363A00000X Physician Assistant (Licence: GA 006436) | |
| Enumeration Date | 2012-06-21 |
| Last Update Date | 2024-05-22 |