| NPI | 1265972814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 026085) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 1138823) |
| Enumeration Date | 2017-03-01 |
| Last Update Date | 2021-07-01 |