| NPI | 1205236536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09230) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 017524) |
| Enumeration Date | 2014-08-22 |
| Last Update Date | 2022-07-11 |