| NPI | 1104182195 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-13048) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-13048) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 016546) | |
| Enumeration Date | 2012-04-04 |
| Last Update Date | 2024-04-15 |