| NPI | 1073527602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 009213) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA051201) |
| Enumeration Date | 2006-07-28 |
| Last Update Date | 2023-03-07 |