| NPI | 1114344769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 23017466) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9110264) |
| Enumeration Date | 2014-03-20 |
| Last Update Date | 2019-12-10 |