| NPI | 1740673920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2928) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TN 2928) |
| 363A00000X Physician Assistant (Licence: NC 0010-05615) | |
| Enumeration Date | 2015-03-11 |
| Last Update Date | 2019-07-03 |