| NPI | 1164784542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NY 020247) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 020247) |
| 133V00000X Dietitian, Registered (Licence: NY 007505-1) | |
| Enumeration Date | 2012-06-12 |
| Last Update Date | 2019-06-18 |