| NPI | 1912464488 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4578-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 022892-1) |
| Enumeration Date | 2019-02-21 |
| Last Update Date | 2019-05-22 |