| NPI | 1720017239 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02246) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 010768) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2012-03-27 |