| NPI | 1063712198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 23-008853) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 002480) |
| Enumeration Date | 2010-10-22 |
| Last Update Date | 2010-10-22 |