| NPI | 1548263882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 009808) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001621) |
| Enumeration Date | 2005-05-31 |
| Last Update Date | 2022-02-10 |