| NPI | 1447539564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 008273) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014914) |
| Enumeration Date | 2011-08-07 |
| Last Update Date | 2020-01-23 |