| NPI | 1821001298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA001838-L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 05503-1) |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2007-07-08 |