| NPI | 1003165184 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 015946) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 0960) |
| 363A00000X Physician Assistant (Licence: MA PA4899) | |
| Enumeration Date | 2012-09-05 |
| Last Update Date | 2014-03-13 |