| NPI | 1831579028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9115123) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110007827) |
| 363A00000X Physician Assistant (Licence: NY 018720) | |
| Enumeration Date | 2015-06-03 |
| Last Update Date | 2022-04-10 |