| NPI | 1578930897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 020479) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA09936) |
| Enumeration Date | 2015-08-24 |
| Last Update Date | 2016-12-15 |