| NPI | 1871680900 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN PA0000001018) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA01018) |
| Enumeration Date | 2006-10-09 |
| Last Update Date | 2008-09-26 |