| NPI | 1104378660 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA MA058993) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NY 020180) |
| Enumeration Date | 2016-11-01 |
| Last Update Date | 2022-07-21 |