| NPI | 1013251040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 0299913) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA055777) |
| Enumeration Date | 2012-11-15 |
| Last Update Date | 2023-09-25 |