| NPI | 1053887836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NY 022981) |
| Enumeration Date | 2018-10-18 |
| Last Update Date | 2021-08-30 |