| NPI | 1861704215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06375) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014013-1) |
| Enumeration Date | 2010-07-13 |
| Last Update Date | 2018-03-17 |