| NPI | 1255350898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 004794) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 05269-1) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2020-12-14 |