| NPI | 1124469432 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 012783) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA002466) |
| Enumeration Date | 2013-07-15 |
| Last Update Date | 2013-07-15 |