| NPI | 1053714188 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 7407) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 029953) |
| 363A00000X Physician Assistant | |
| 363A00000X Physician Assistant (Licence: NC 0010-13873) | |
| 363A00000X Physician Assistant (Licence: MA PA9383) | |
| Enumeration Date | 2014-10-03 |
| Last Update Date | 2025-03-17 |