| NPI | 1285803171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA053388) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 011483) |
| Enumeration Date | 2008-02-25 |
| Last Update Date | 2015-10-15 |