| NPI | 1295757722 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA MA052899) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 007148) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2020-01-14 |