| NPI | 1205239993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 018122-1) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110005352) |
| Enumeration Date | 2014-10-08 |
| Last Update Date | 2020-05-22 |