| NPI | 1003861550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 008446) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00219200) |
| 363A00000X Physician Assistant (Licence: FL PA 9103562) | |
| Enumeration Date | 2006-05-23 |
| Last Update Date | 2020-10-22 |