| NPI | 1487631289 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1033611) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 011211-1) |
| Enumeration Date | 2005-12-22 |
| Last Update Date | 2016-02-03 |