| NPI | 1558502732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0003242) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9103652) |
| 363A00000X Physician Assistant (Licence: NY 021915) | |
| Enumeration Date | 2009-03-17 |
| Last Update Date | 2018-05-21 |