| NPI | 1457633943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA055017) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 015034) |
| Enumeration Date | 2011-09-12 |
| Last Update Date | 2022-10-07 |