| NPI | 1992183412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TN PA2743) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 2743) |
| Enumeration Date | 2015-05-16 |
| Last Update Date | 2020-08-27 |