| NPI | 1396859062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA056726) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 1379) |
| 363A00000X Physician Assistant (Licence: NY 021855) | |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2018-04-19 |