| NPI | 1396581450 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14534) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: NY 032143) | |
| Enumeration Date | 2024-07-08 |
| Last Update Date | 2024-10-10 |