| NPI | 1376506998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110008805) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 008501) |
| Enumeration Date | 2006-04-07 |
| Last Update Date | 2025-01-28 |