| NPI | 1063189025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010741) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 027545) |
| 363A00000X Physician Assistant (Licence: CT 7186) | |
| 363A00000X Physician Assistant (Licence: MD C0009935) | |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2021-08-26 |
| Last Update Date | 2025-08-06 |