| NPI | 1366012767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 026729) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085009770) |
| 363A00000X Physician Assistant (Licence: OH 50.008156RX) | |
| 363A00000X Physician Assistant (Licence: IN 10004243A) | |
| 363A00000X Physician Assistant (Licence: MI 5601011766) | |
| Enumeration Date | 2021-06-28 |
| Last Update Date | 2024-03-21 |