| NPI | 1386784262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 006559) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 4714) |
| Enumeration Date | 2007-02-08 |
| Last Update Date | 2021-10-18 |