| NPI | 1417916024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA052217) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 011058-1) |
| Enumeration Date | 2006-03-22 |
| Last Update Date | 2011-07-29 |