| NPI | 1215596317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 024896) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ND PAC0965) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA060726) | |
| Enumeration Date | 2019-06-12 |
| Last Update Date | 2024-08-29 |