| NPI | 1801876040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01043) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA001621L) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 004628-1) | |
| Enumeration Date | 2006-01-21 |
| Last Update Date | 2015-05-20 |