| NPI | 1275846511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DC PA031007) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NY 014135) |
| Enumeration Date | 2010-07-15 |
| Last Update Date | 2016-12-13 |