| NPI | 1699166231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 4645) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05492) |
| Enumeration Date | 2015-02-17 |
| Last Update Date | 2022-03-26 |