NPI | 1669109963 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA065466) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 1190047) |
Enumeration Date | 2022-08-05 |
Last Update Date | 2024-06-19 |