| NPI | 1205382744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 020233) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00404600) |
| Enumeration Date | 2016-08-25 |
| Last Update Date | 2018-12-19 |