| NPI | 1174117907 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 026512) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61260172) |
| Enumeration Date | 2021-02-23 |
| Last Update Date | 2023-10-26 |