| NPI | 1639323066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06376) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012889) |
| Enumeration Date | 2008-11-12 |
| Last Update Date | 2017-02-08 |