| NPI | 1700096963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110002952) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 011817) |
| Enumeration Date | 2007-05-23 |
| Last Update Date | 2010-10-18 |