| NPI | 1235589037 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA7835) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020133) |
| Enumeration Date | 2016-06-13 |
| Last Update Date | 2021-03-15 |