| NPI | 1457624058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 5365) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015478) |
| Enumeration Date | 2012-02-14 |
| Last Update Date | 2024-07-13 |