| NPI | 1821450750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN PA0000002960) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TN PA0000002960) |
| Enumeration Date | 2016-03-21 |
| Last Update Date | 2019-08-23 |