| NPI | 1124369707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061178) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 23 016460) |
| 363A00000X Physician Assistant (Licence: GA 007090) | |
| Enumeration Date | 2013-03-07 |
| Last Update Date | 2020-02-11 |