| NPI | 1922036862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07526) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2826) |
| 363A00000X Physician Assistant (Licence: NY 010469) | |
| Enumeration Date | 2006-06-29 |
| Last Update Date | 2023-10-19 |