| NPI | 1194725788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 13115) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 003405) |
| Enumeration Date | 2005-07-26 |
| Last Update Date | 2026-01-06 |