| NPI | 1902894389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 580) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN PA580) |
| 363A00000X Physician Assistant (Licence: UT 10261499-1206) | |
| Enumeration Date | 2005-10-11 |
| Last Update Date | 2026-05-13 |