| NPI | 1407884950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9100970) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 010532) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2021-03-11 |