| NPI | 1740439462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TN PA2633) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OH 50-002801) |
| Enumeration Date | 2008-09-18 |
| Last Update Date | 2015-05-13 |