| NPI | 1801374566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13163) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 022396) |
| 363A00000X Physician Assistant (Licence: NY 22396) | |
| Enumeration Date | 2018-08-03 |
| Last Update Date | 2023-07-17 |