| NPI | 1700989894 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2386) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 003344) |
| Enumeration Date | 2006-09-06 |
| Last Update Date | 2021-01-27 |