| NPI | 1821388638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9917) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 007176) |
| Enumeration Date | 2011-04-13 |
| Last Update Date | 2023-06-22 |