| NPI | 1972866374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2327) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-03599) |
| Enumeration Date | 2012-06-20 |
| Last Update Date | 2013-05-17 |