| NPI | 1366012999 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 026866) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 10390) |
| Enumeration Date | 2021-06-27 |
| Last Update Date | 2023-08-07 |