| NPI | 1487631198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 007250) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 0072501) |
| Enumeration Date | 2005-12-23 |
| Last Update Date | 2016-09-26 |