| NPI | 1154373983 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12474) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 009787-1) |
| 363AM0700X Physician Assistant, Medical (Licence: IA 001382) | |
| Enumeration Date | 2006-05-17 |
| Last Update Date | 2022-08-01 |