| NPI | 1891821674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 1707) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC TL1298) |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2010-06-15 |