| NPI | 1750482600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-04363) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 006908) |
| Enumeration Date | 2006-09-25 |
| Last Update Date | 2023-08-03 |