| NPI | 1639436264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107769) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015566) |
| Enumeration Date | 2012-04-20 |
| Last Update Date | 2023-07-03 |