| NPI | 1366619868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 8329) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012269) |
| Enumeration Date | 2008-05-14 |
| Last Update Date | 2018-03-17 |