| NPI | 1336220573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 014890) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1071721) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2016-10-10 |