| NPI | 1053579417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06371) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 005761) |
| Enumeration Date | 2008-06-01 |
| Last Update Date | 2016-12-02 |