| NPI | 1265796577 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003943) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 018934) |
| Enumeration Date | 2012-07-02 |
| Last Update Date | 2022-08-18 |