| NPI | 1114915790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01048) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 0010-01048) |
| 363AM0700X Physician Assistant Medical (Licence: NY 0054831) | |
| Enumeration Date | 2005-10-08 |
| Last Update Date | 2024-10-16 |