| NPI | 1114326055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 7669) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 017861) |
| Enumeration Date | 2014-08-16 |
| Last Update Date | 2016-09-13 |