| NPI | 1023076643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 1089) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA AP1946) |
| 363A00000X Physician Assistant (Licence: NY 027167) | |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2021-10-29 |