| NPI | 1710251350 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2106) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 7027) |
| 363AS0400X Physician Assistant Surgical (Licence: TN 2106) | |
| Enumeration Date | 2012-02-29 |
| Last Update Date | 2020-12-01 |