| NPI | 1073897369 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA055138) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MH2621402) |
| Enumeration Date | 2011-10-05 |
| Last Update Date | 2025-02-26 |