| NPI | 1154696029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 015499) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 15499) |
| Enumeration Date | 2012-03-12 |
| Last Update Date | 2023-07-06 |