| NPI | 1891750097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004367) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA0000001123) |
| Enumeration Date | 2006-04-19 |
| Last Update Date | 2019-12-17 |