| NPI | 1154660637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 016324) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 016324) |
| Enumeration Date | 2013-02-04 |
| Last Update Date | 2017-05-09 |