| NPI | 1952303679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 7600) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 101711) |
| 363AM0700X Physician Assistant, Medical (Licence: TN PA1823) | |
| Enumeration Date | 2005-08-12 |
| Last Update Date | 2023-11-27 |