| NPI | 1124061585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 47000) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 007884-1) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2022-01-10 |