| NPI | 1366872616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA056636) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA003198) |
| 363A00000X Physician Assistant (Licence: NY 017169-1) | |
| Enumeration Date | 2013-11-23 |
| Last Update Date | 2013-11-23 |