| NPI | 1255391793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 001190-1) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV 464) |
| Enumeration Date | 2006-03-27 |
| Last Update Date | 2009-10-22 |