| NPI | 1659867711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 11005) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 022090) |
| Enumeration Date | 2018-07-02 |
| Last Update Date | 2023-04-21 |