| NPI | 1841232295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07376) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 011023) |
| 363AM0700X Physician Assistant, Medical (Licence: CT 001746) | |
| Enumeration Date | 2006-06-11 |
| Last Update Date | 2025-02-10 |