| NPI | 1215948237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-971) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 8623-1) |
| 363A00000X Physician Assistant (Licence: ID PA440) | |
| 363AM0700X Physician Assistant Medical (Licence: NY 8623-1) | |
| Enumeration Date | 2006-08-11 |
| Last Update Date | 2022-10-13 |