| NPI | 1386681211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 010749) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC SC4401) |
| Enumeration Date | 2006-05-31 |
| Last Update Date | 2024-01-24 |