| NPI | 1376737411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C05654) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 012255) |
| 363A00000X Physician Assistant (Licence: VA 0110003850) | |
| Enumeration Date | 2007-08-31 |
| Last Update Date | 2023-10-16 |