| NPI | 1003209396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA057503) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020499) |
| Enumeration Date | 2015-03-10 |
| Last Update Date | 2021-01-16 |