| NPI | 1740610377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9115794) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 017058) |
| Enumeration Date | 2013-11-18 |
| Last Update Date | 2023-11-22 |