| NPI | 1013961317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 3578) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 001906) |
| Enumeration Date | 2006-05-20 |
| Last Update Date | 2020-10-15 |