| NPI | 1154621860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 4883) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014255) |
| Enumeration Date | 2010-10-27 |
| Last Update Date | 2017-10-26 |