| NPI | 1386300507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063251) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 030779) |
| 363A00000X Physician Assistant (Licence: CA 63170) | |
| 363A00000X Physician Assistant (Licence: OH 50.008492RX) | |
| 363A00000X Physician Assistant (Licence: RI PA01645) | |
| Enumeration Date | 2021-11-11 |
| Last Update Date | 2023-12-17 |