| NPI | 1255701728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10979) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 019061) |
| Enumeration Date | 2015-09-28 |
| Last Update Date | 2022-06-16 |