| NPI | 1265599674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 779) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 008720) |
| Enumeration Date | 2007-01-03 |
| Last Update Date | 2013-08-20 |