| NPI | 1801149612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 7586) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015983) |
| Enumeration Date | 2012-10-17 |
| Last Update Date | 2018-11-28 |