| NPI | 1215980024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA053833) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110000122) |
| 363A00000X Physician Assistant (Licence: NY 003696) | |
| 363AM0700X Physician Assistant, Medical (Licence: VA 0110000122) | |
| Enumeration Date | 2006-05-19 |
| Last Update Date | 2025-07-16 |