| NPI | 1912605262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 5388) |
| Additional Taxonomies | 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: TN 000000-850) |
| Enumeration Date | 2023-02-16 |
| Last Update Date | 2023-04-13 |