| NPI | 1174693931 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 005200) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 009452-1) |
| Enumeration Date | 2006-11-09 |
| Last Update Date | 2018-12-20 |