| NPI | 1508316803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110009098) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020205) |
| Enumeration Date | 2016-10-11 |
| Last Update Date | 2025-12-30 |