| NPI | 1699964262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14359) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012117) |
| Enumeration Date | 2007-10-19 |
| Last Update Date | 2026-02-23 |