| NPI | 1881739456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110006963) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA052240) |
| 363A00000X Physician Assistant (Licence: NY 004921) | |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2025-04-29 |