| NPI | 1346682622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 021544) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WY PT617) |
| Enumeration Date | 2013-07-26 |
| Last Update Date | 2018-01-25 |