| NPI | 1821613100 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-16136) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 029124) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2020-06-11 |
| Last Update Date | 2026-01-22 |