| NPI | 1760420640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 1152) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA829) |
| 363A00000X Physician Assistant (Licence: ND PAC0546) | |
| 363A00000X Physician Assistant (Licence: FL PA9111356) | |
| 363A00000X Physician Assistant (Licence: GA 8818) | |
| Enumeration Date | 2006-06-03 |
| Last Update Date | 2024-08-09 |