| NPI | 1093173205 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY P00580) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 019511) |
| Enumeration Date | 2016-02-02 |
| Last Update Date | 2022-03-15 |