| NPI | 1275707895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106498) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 004944-1) |
| Enumeration Date | 2008-04-15 |
| Last Update Date | 2022-02-25 |