| NPI | 1225557465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DC PA031394) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C06571) |
| 363A00000X Physician Assistant (Licence: VA 0110005861) | |
| 363A00000X Physician Assistant (Licence: NY 21239) | |
| Enumeration Date | 2017-09-19 |
| Last Update Date | 2023-06-29 |