| NPI | 1699004556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: VA 0110004260) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NY 13758) |
| 363AM0700X Physician Assistant Medical (Licence: NY 013758) | |
| Enumeration Date | 2009-12-23 |
| Last Update Date | 2023-07-03 |