| NPI | 1700166188 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003604) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 1995) |
| Enumeration Date | 2011-08-17 |
| Last Update Date | 2018-06-05 |