| NPI | 1972540334 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 0799) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY 1776) |
| Enumeration Date | 2006-06-02 |
| Last Update Date | 2022-05-31 |