| NPI | 1053762781 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 019744) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA059543) |
| Enumeration Date | 2016-06-23 |
| Last Update Date | 2022-04-07 |