| NPI | 1114979689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4274) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 004235) |
| Enumeration Date | 2006-05-16 |
| Last Update Date | 2022-02-02 |