| NPI | 1972000677 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NY 024237) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1140276) |
| 363A00000X Physician Assistant (Licence: GA 8743) | |
| Enumeration Date | 2018-04-09 |
| Last Update Date | 2020-10-20 |