| NPI | 1881167674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 026538) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 9162) |
| Enumeration Date | 2019-01-04 |
| Last Update Date | 2021-09-02 |