| NPI | 1376016873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 023345) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 002248) |
| Enumeration Date | 2019-01-07 |
| Last Update Date | 2021-04-23 |