| NPI | 1891078994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 015110-1) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA60217363) |
| Enumeration Date | 2011-09-25 |
| Last Update Date | 2011-09-25 |