| NPI | 1083055768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110-005565) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 016581) |
| Enumeration Date | 2013-07-10 |
| Last Update Date | 2023-11-07 |