| NPI | 1356351399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13666) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 009568-0) |
| Enumeration Date | 2006-08-09 |
| Last Update Date | 2024-03-04 |