| NPI | 1417980392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 014770-1) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-00836) |
| 363AM0700X Physician Assistant, Medical (Licence: RI PA00357) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-00836) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 014770-1) | |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2023-03-07 |