| NPI | 1750797700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2590) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MS PA00219) |
| Enumeration Date | 2014-07-09 |
| Last Update Date | 2022-03-14 |