| NPI | 1538471180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 013931) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2010011928) |
| 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00336100) | |
| Enumeration Date | 2010-07-12 |
| Last Update Date | 2015-01-19 |