| NPI | 1467775361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA056290) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 013747) |
| Enumeration Date | 2010-03-05 |
| Last Update Date | 2021-03-25 |