| NPI | 1255636700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 014547) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA058234) |
| 363AM0700X Physician Assistant, Medical (Licence: CA 62734) | |
| 363AM0700X Physician Assistant, Medical (Licence: IL 085009447) | |
| Enumeration Date | 2011-01-13 |
| Last Update Date | 2024-02-27 |