| NPI | 1801032461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN PA2902) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA2234) |
| Enumeration Date | 2008-12-31 |
| Last Update Date | 2023-02-02 |