| NPI | 1912201302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14515) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 013587) |
| Enumeration Date | 2010-12-29 |
| Last Update Date | 2024-09-09 |