| NPI | 1811235419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107032) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA0000002770) |
| Enumeration Date | 2013-01-17 |
| Last Update Date | 2019-03-05 |