| NPI | 1104225119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 8577) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 017836) |
| Enumeration Date | 2014-08-14 |
| Last Update Date | 2025-05-20 |