| NPI | 1194134783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08302) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 017848) |
| Enumeration Date | 2014-08-07 |
| Last Update Date | 2021-05-25 |