| NPI | 1790733368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110001755) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 023550) |
| Enumeration Date | 2006-05-05 |
| Last Update Date | 2019-08-15 |