| NPI | 1568831543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9109543) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 019074) |
| Enumeration Date | 2015-09-18 |
| Last Update Date | 2021-03-17 |