| NPI | 1306235247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 018365) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 52270) |
| 363A00000X Physician Assistant (Licence: MN 11825) | |
| Enumeration Date | 2015-01-15 |
| Last Update Date | 2015-09-09 |