| NPI | 1982290557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14229) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 027709) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-14229) | |
| Enumeration Date | 2020-12-17 |
| Last Update Date | 2025-01-10 |