| NPI | 1568827442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 019382) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA0000002896) |
| Enumeration Date | 2015-12-21 |
| Last Update Date | 2015-12-21 |