| NPI | 1417386673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 017566) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 055.0031190) |
| Enumeration Date | 2013-11-07 |
| Last Update Date | 2015-07-28 |