| NPI | 1942242086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA051745) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-00957) |
| 363A00000X Physician Assistant (Licence: NY 014669) | |
| Enumeration Date | 2006-06-12 |
| Last Update Date | 2012-01-31 |