| NPI | 1023669801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060928) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 024073) |
| Enumeration Date | 2019-09-24 |
| Last Update Date | 2021-03-14 |