| NPI | 1821102203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 005639) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 002999) |
| 363A00000X Physician Assistant (Licence: MD C0003531) | |
| 363AM0700X Physician Assistant Medical (Licence: NY 005639) | |
| Enumeration Date | 2006-08-19 |
| Last Update Date | 2023-10-03 |