| NPI | 1477806438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 1016380 PA-C NCCPA#) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 7937253) |
| 363A00000X Physician Assistant (Licence: MD C0001101) | |
| Enumeration Date | 2012-10-16 |
| Last Update Date | 2012-10-16 |