| NPI | 1386762912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR 179767) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 0075241) |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2018-03-28 |