| NPI | 1487887543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4311) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 013445) |
| Enumeration Date | 2009-08-24 |
| Last Update Date | 2022-02-25 |