| NPI | 1801066055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12251) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012432-1) |
| Enumeration Date | 2008-03-04 |
| Last Update Date | 2022-05-18 |