| NPI | 1124137864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 2189) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 011042) |
| Enumeration Date | 2006-08-29 |
| Last Update Date | 2013-05-23 |